Clinical experience with urgent tube shunt implantation through the ciliary sulcus in phakic eyes.

PURPOSE: To review the clinical course and outcomes of 3 phakic, ischemic, and inflamed eyes in which we performed urgent tube shunt implantation through the ciliary sulcus without lensectomy. METHODS: This is a retrospective interventional case series. Three eyes of 3 diabetic patients with uncontrolled severe neovascular glaucoma, shallow anterior chambers with closed angles and poor view to the posterior segment, where concomitant lensectomy was not recommended due to uncontrolled uveitis and ischemia, underwent tube shunt implantation through the ciliary sulcus. Main outcome measures were surgical complications, especially injury to the crystalline lens, and postoperative intraocular pressure (IOP). RESULTS: No surgical complications, including injury to the crystalline lens, have occurred. We used surgical modifications to allow sufficient visualization of the sulcus area to avoid injury to the crystalline lens during scleral tunneling and tube insertion through the ciliary sulcus. Postoperatively, the uveitis, ischemia, and vision have improved and IOP was controlled throughout follow-up. Cataract surgery with pupilloplasty was performed in one eye a year later with no complications and no interruption to IOP control. CONCLUSIONS: Based on our small and limited retrospective study, and under unusual circumstances, urgent tube shunt implantation through the ciliary sulcus may be considered in phakic eyes with severely uncontrolled IOP, shallow anterior chambers and poor view to the posterior segment, and when concomitant lensectomy is not recommended. We advise the use of appropriate surgical modifications by experienced glaucoma surgeons to prevent intraoperative complications. Further and larger studies are needed to evaluate the safety of this surgical option.

Corneal Parameters after Tube-Shunt Implantation through the Ciliary Sulcus.

PURPOSE: To monitor bilateral corneal parameters after unilateral Baerveldt 350 tube-shunt implantation (Advanced Medical Optics, Santa Ana, CA) through the ciliary sulcus. DESIGN: Retrospective, interventional case series. PARTICIPANTS: Patients from 1 private glaucoma practice with severe uncontrolled glaucoma treated with sulcus tube-shunt implantation in 1 pseudophakic eye. METHODS: Specular microscopy data were collected before and after unilateral sulcus tube-shunt implantation from the surgical and the glaucomatous fellow eyes. MAIN OUTCOME MEASURES: Central corneal endothelial cell density (CECD), coefficient of variation (CV), percent of hexagonal cells, central corneal thickness (CCT), intraocular pressure (IOP), IOP-lowering medications, visual acuity, and complications. RESULTS: Forty-six patients (mean age, 69.9 years; standard deviation [SD], 4.6 years; range, 20-88 years; male gender, 41.3%) were identified. After surgery, IOP and the number of IOP-lowering medications decreased significantly by 42.3% (P < 0.0001) and 32.1% (P < 0.0001), respectively, in the surgical eye group. Preoperative CECD measured 1807 cells/mm2 (SD, 172 cells/mm2) and 1825 cells/mm2 (SD, 172 cells/mm2) in the surgical and fellow eyes, respectively (P = 0.92), and compared with baseline, it decreased by 8.6% (P = 0.17) and 3.1% (P = 0.65), respectively, by 24 months. Preoperative CV, percent of hexagonal cells, and CCT were similar in both groups and remained stable. All corneal parameters remained unchanged in a subgroup of 15 patients with low preoperative CECD (1273 cells/mm2; SD, 99 cells/mm2). Best-corrected visual acuity remained stable in both groups. Hyphema occurred in 23.9% of the surgical eyes and resolved with no intervention. We found no sight-threatening complications or corneal failures during follow-up. CONCLUSIONS: Tube-shunt implantation through the ciliary sulcus in pseudophakic eyes appears relatively safe to the corneal endothelium, demonstrating a small and nonsignificant decline in central CECD compared with baseline and with glaucomatous fellow eyes. No significant disruption to corneal endothelial cell morphologic features, increased corneal thickness, or corneal failures were found during the 24-month follow-up period. A prospective head-to-head comparison to assess the effects of the various methods of tube-shunt implantation on the corneal endothelium is needed.

Intraocular Pressure After Cataract Surgery Combined With Ab Interno Trabeculectomy Versus Trabecular Micro-bypass Stent: An Intrasubject Same-surgeon Comparison.

PRECIS: Combining Trabectome or iStent with phacoemulsification equally reduces intraocular pressure (IOP) and IOP-lowering medication burden during a 24-month follow-up, with a possible advantage to the Trabectome in the early postoperative period. PURPOSE: Intrasubject same-surgeon comparison between phacoemulsification combined with Trabectome (Phaco/Trabectome) versus one first-generation iStent (Phaco/iStent). SETTINGS: Private glaucoma and cataract practice. DESIGN: This is a retrospective interventional case series. METHODS: Data collected at 3 to 4 and 20 to 24 hours and up to 30 months following Phaco/Trabectome in 1 eye and Phaco/iStent in the contralateral eye in patients with bilateral visually-significant cataract and open-angle glaucoma. Evaluations included IOP, intraocular pressure-lowering medications (IOPmeds), visual acuity, and complications. RESULTS: Forty-five patients (90 eyes) were identified (age 76.5, 57 to 95 y). At 3 to 4 hours, IOP was above baseline in 12 and 13 eyes following Phaco/Trabectome and Phaco/iStent, respectively, but the degree of IOP elevation was smaller (P=0.048) following Phaco/Trabectome: 4.3 mm Hg, 2.0 to 6.6 mm Hg (95% confidence interval) versus Phaco/iStent: 8.7 mm Hg, 3.8 to 13.6 mm Hg. At 20 to 24 hours, compared with baseline, IOP was significantly lower after Phaco/Trabectome (P=0.004) but not after Phaco/iStent (P=0.14) although the rate of hyphema was higher following Phaco/Trabectome (12/45 vs. 2/45 eyes, P=0.007). IOP reduction from baseline at 3 to 4 hours was significantly larger (P=0.020) in the 21 eyes with hyphema: -3.9, -6.4 to -1.4 versus the 69 eyes without hyphema: -0.3, -2.0 to +1.4. At 1, 6, 12, and 24 months, IOP and number of IOPmeds were similar and significantly lower compared with baseline following either procedure. No complications were encountered in either group. CONCLUSIONS: Combined phacoemulsification with either Trabectome or first-generation iStent similarly lowers IOP and IOPmeds burden at 1, 6, 12, and 24 months following surgery. The Trabectome may have an advantage in lowering IOP faster and lessening the degree of IOP elevations in the early postoperative period.

Intraocular pressure 3 to 4 hours and 20 hours after cataract surgery with and without ab interno trabeculectomy.

PURPOSE: To evaluate intraocular pressure (IOP) immediately after cataract surgery with or without ab interno trabeculectomy (Trabectome) and whether trabeculectomy-related hyphema increases the risk for IOP spikes. SETTINGS: Private glaucoma practice. DESIGN: Retrospective interventional nonrandomized comparative chart review. METHODS: Intraocular pressure was measured 3 to 4 hours and 20 hours postoperatively. RESULTS: The combined group comprised 73 eyes of 73 patients and the cataract-only group, 75 eyes of 75 patients. The mean preoperative IOP was 15.8 mm Hg ± 3.6 (SD) and 14.9 ± 3.0 mm Hg, respectively (P = .09). In the combined group, the IOP decrease was significant at 3 to 4 hours (P = .0003) and 20 hours (P = .0007). In the cataract-only group, the IOP increased significantly (P < .0001 and P = .0035, respectively). The mean IOP was significantly lower in the combined group than in the cataract-only group at 3 to 4 hours (12.8 ± 5.9 mm Hg versus 19.7 ± 7.5 mm Hg) and 20 hours (12.7 ± 7.0 mm Hg versus 17.2 ± 5.9 mm Hg) (both P < .0001). Significantly fewer eyes in the combined group than in the cataract-only group had IOP spikes (overall, P = .0077; 3 to 4 hours, P = .001). Hyphema occurred in 35 eyes (47.9%) in the combined group; however, the IOP was similar with or without hyphema. Only 1 eye with an IOP spike in the combined group had hyphema. CONCLUSION: Combining ab interno trabeculectomy and cataract surgery reduced short-term postoperative IOP and the incidence of IOP spikes despite the common hyphema. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Clinical experience with sulcus-implanted Baerveldt glaucoma tube shunts fully concealed behind the iris in undilated pseudophakic eyes.

PURPOSE: To describe our clinical experience with ciliary sulcus-implanted Baerveldt glaucoma tube shunts entirely concealed behind the iris in undilated pseudophakic eyes (concealed tubes, CT group), compared with similarly implanted tubes whose openings remain fully exposed in the undilated pupillary area (nonconcealed tubes, NCT group). METHODS: A retrospective interventional nonrandomized comparative chart review. The main outcome measures were postoperative tube incarceration by the iris, and postoperative intraocular pressure (IOP) and the number of IOP-lowering medications. RESULTS: Fifteen eyes of 15 patients were identified in the CT group and 41 eyes of 41 patients in the NCT group. In the CT and NCT groups, the postoperative follow-up period was 14.4±10.2 months (mean±SD; range, 3 to 42 mo) and 22.9±18.1 months (mean±SD; range, 3 to 72 mo; P=0.08), respectively. Only 1 case of tube incarceration by the iris has occurred in the CT group (6.7%) and none in the NCT group. This eye was treated with laser iridotomy with no recurrence. Preoperative IOPs in the CT and the NCT groups were 27.2±9.6 mm Hg (mean±SD; range, 16 to 46 mm Hg) and 25.5±10.6 mm Hg (mean±SD; range, 12 to 59 mm Hg; P=0.6), respectively. The IOPs were significantly reduced to 13.3±4.1 mm Hg (mean±SD; range, 6 to 22 mm Hg; P=0.0001) and 10.8±4.4 mm Hg (mean±SD; range, 4 to 25 mm Hg; P=0.0001), respectively, at the final visit. The difference in the final visit IOP between the groups approached significance (P=0.056). The number of preoperative IOP-lowering medications was 3.9±0.7 (mean±SD; range, 2 to 5) and 4.0±1.0 (mean±SD; range, 1 to 6), respectively. It was significantly reduced to 1.9±1.2 (mean±SD; range, 0 to 4; P=0.0001) and 1.8±1.4 (mean±SD; range, 0 to 5; P=0.0001), respectively. There was no significant difference between the groups before (P=0.6) or after surgery (P=0.8). CONCLUSIONS: Although NCTs tend to have a lower final IOP compared with CTs, the latter are safe and effective and do not require surgical repositioning. Should a CT become occluded by the iris, an uncommon event in our study, it could be treated by laser iridotomy alone.